Savita – never again

We now know with a reasonable degree of certainty what caused the tragic death of Savita Halappanavar. Yesterday’s HSE report under the chairmanship of Prof Sabaratnam Arulkumaran, provides a clear, detailed account, hour by hour, of the painful last seven days of the 31-year-old’s life and a persuasive analysis of the many contributing factors to her death. The report’s important recommendations deserve the prompt implementation which the report itself demands.

Inadequately-followed clinical guidelines for the management of sepsis, and failures in the monitoring and assessing of her condition compounded decisions “not to offer all management options to the patient as she experienced inevitable miscarriage, even though the risk she faced increased from the time her membranes ruptured” on the Monday of that week. “This appears to have been either due to the way the law was interpreted in dealing with the case or the lack of appreciation of the increasing risk to the mother and the earlier need for delivery of the foetus,” the report says.

The decision not to offer the termination that she would probably have got in most other Irish hospitals, has played into the public abortion/X case debate – the argument being that it is precisely the lack of clarity about where the law stands and the inadequacy of medical guidelines that need to be remedied.

That case is endorsed by the report which insists the Government and medical profession must urgently consider legal, perhaps Constitutional, changes as well as new clinical guidelines for second-trimester management in circumstances of inevitable miscarriage. The absence of such guidelines internationally it associates with the reality such conditions would elsewhere have led to early termination.

The report also urges procedural tightening of case management; use of early warning score charts, of training for all staff in the monitoring/management of sepsis, publication of national guidelines, the systematic auditing of practice, and improved guidelines for the consultant-on-call system. All need to be implemented if this tragedy is not to be repeated.

It is also worth considering whether this important report would ever have been commissioned, or indeed whether the rethinking of both the legal framework for terminations and care standards would have happened, without the light shone on this case from outside the health system, as it happens, by this paper’s initial report on the tragedy.

There are attempts to improve transparency. The automatic reporting of all terminations to the Minister provided for in the new Protection of Life during Pregnancy Bill is welcome, but does not go far enough. There should also be a requirement to report all requests for terminations, the outcome of such requests, and when refused the circumstances of the refusal.

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